Tricare Prime - Getting out, military health issues - Navy Times

Tricare Prime

Prime is a Tricare option similar to a health maintenance organization, which has lower out-of-pocket costs but requires enrollees to use network providers and coordinate their care through a primary care manager — a doctor, nurse practitioner or team — who provides treatment and coordinates aspects of their health care.

Prime requires enrollment. There is no enrollment fee for active-duty members or their families, but retirees pay $230 for an individual or $460 for a family each year. There is a Tricare Prime option available overseas for active-duty troops and their command-sponsored family members. Prime is not available to retirees overseas.

Individuals enrolled in Prime at military hospitals and clinics get higher priority for care than those not enrolled. Enrolled active-duty family members have priority just after service members. Enrolled retirees and their families are seen next, followed by active-duty family members not enrolled in Prime.

Prime enrollees referred to a specialist more than 100 miles from their primary care facility can have their travel costs reimbursed.

Prime limits out-of-pocket expenses; it has no deductibles, and co-payments for health care visits are lower than for the other programs.

Co-pays for outpatient civilian doctor visits are $12 for enrolled retirees and their family members. Active-duty family members don’t pay for civilian medical care if they follow the Prime rules. They do pay for civilian pharmacy services. The catastrophic cap — the ceiling on how much a family must pay annually for Tricare-covered health care services — is $1,000 for active-duty families and $3,000 for retirees’ families, provided they follow the rules.

Costs rise substantially if a Prime enrollee goes outside the Tricare network without authorization from the primary care provider using the point-of-service option. In such instances, deductibles are $300 for an individual or $600 for a family. After the deductible is met, Tricare will pay only 50 percent of what it establishes as the Tricare allowable charge.

Contact: www.tricare.mil/mybenefit /home/overview/Plans